Is Stigma More Harmful than Heroin?

Since America’s founding, our relationship with dependence has been fraught at best, fatal at worst. “Independence!” we cry, charging forth across a country we stole, armed with devices we cannot live without. The terms within which we discuss addiction have been moralized, medicalized, and politicized in waves for the past century.

The temperance movement began appropriating the word “addiction” as the name of a moral failure around the same time that the medical profession began appropriating it as the name of a disease. It entered the Oxford English Dictionary as a medical/moral pejorative for the first time in 1933, nearly a hundred years after the first Opium Wars in China.

In reality, psychoactive substances are but threads in a larger tapestry of addiction and addictive behavior (just look at our country’s relationship with sugar, caffeine, capital, etc.). Yet stigmatizing drug use is one of the last forms of publicly acceptable bigotry.

“Drug use is part of the human condition,” states Greg Scott, Director of the Chicago Recovery Alliance (CRA). Scott, also a Professor of Sociology at DePaul University and Director of the Social Science Research Center, has been working in harm reduction since 2000 and joined the CRA as Director of Research in January of 2001.

The CRA website describes harm reduction as a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction Coalition is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. The Alliance is committed to supporting those living with HIV and drug use by providing them with a wide array of options for achieving “any positive change as they define it for themselves.” This includes safe injection sites, needle exchanges, counseling, and a judgement-free community.

Besides providing counseling services and safe environments for drug use, harm reduction advocates also aim to foment a sense of community for people who use drugs.

“What we do is a relationship-based approach,” explains Scott. “Harm reduction is centered on the idea of forming trust-laden relationships with the most marginalized people in the country. And they are the most marginalized people by virtue of what they do to alter their consciousness.”

Most marginalized in the sense that they are estranged from conventional medical care, and often even from their families. They have been stigmatized and rejected because of what they choose to put in their bodies in order to alter their consciousness of the world.

The American Medical Association has recognized addiction as a disease since the 1950’s. According to Scott, this helps a little bit politically, however it doesn’t get much cultural traction and is definitely irrelevant to real, interpersonal relationships happening in real time. This is where displacement becomes a vicious circle.

The pain that exists for people who use drugs does not come from the substances themselves, rather it comes from estrangement, stigmatization, displacement, and ultimately the loss of community and isolation — which only serves to propel a person further into an unhealthy relationship with any given substance.

Some harm reduction advocates put forth the Dislocation Theory, in opposition to the Disease Model of Addiction. Dislocation refers to the rupture of enduring and sustaining connections between individuals and their families, friends, societies, livelihoods, rituals, traditions, nations, and deities. “Dislocation Theory does not view addiction as either a medical condition or a moral failure. Rather, it depicts addiction as a way of adapting to increasingly dominant and onerous aspects of the modern world in particular, social fragmentation and individual dislocation,” writes Bruce K. Alexander in The Rise and Fall of the Official View of Addiction.

For example, it is often the case that people suffering from health issues unrelated to their drug use get turned away from care because of their dependencies, as if using a substance makes a person less worthy of treatment, less worthy of life. For many years, Medicare could deny Hepatitis C treatment to a patient suffering from anything short of stage four liver failure if the patient had ever used substances, including alcohol.

These regulations have recently been relaxed, but physicians can still deny treatment at their discretion, which centers the locus of treatment around a fallacious morality, one that allows humans to play God to deem some humans worthy of life and others not.

Some people see the Disease Model of Addiction as yet another way to conduct surveillance of people who use drugs. The Foucauldian oppression-through-surveillance model includes classification, categorization, and the use of multiple systems (medical, law enforcement, mental health, etc.) that are all-surrounding and enveloping of the lives of people who use drugs.

The harm reduction standpoint is essentially “No, this is just what humans do,” which Scott says there’s a problem with when taken as an absolute, as some people who use heroin are using in deeply unhealthy ways.

“There’s always a small percentage of regular users who are experiencing very problematic relationships with these substances meaning it’s unmanageable, there is continued use despite known adverse consequences, and this use negatively impacts other areas of their lives, the three main diagnostic criteria for addiction,” offers Scott. “So we see a very small percentage of people representing a large share of the problems associated with drug use. Just like a certain percentage of people who have disposable income have deeply problematic relationships with disposable income.”

These are the stories we read about in the New Yorker, the stories we rally around as a culture, easily pitting the big pharma fat cats against the innocent but ultimately morally-wayward users, never stopping to consider how easily these stories fit into our larger cultural narrative of fear and prohibition.

The term “epidemic” gets used and suddenly we are absolved of our cultural responsibility to take care of the marginalized.

There is a fatal misconception that people who use drugs are irresponsible or have a death wish. “Just by virtue of them coming to see us [at the Chicago Recovery Alliance], it’s clear that they want to be as healthy as they possibly can. In the context of a race war which is known as the war on drugs we are essentially field medics trying to dress the wounds as best we can and help people stay alive in ways that make sense for them. Some of those folks are going to want to taper down, some are going to want to stop using, but you don’t have those choices if you’re dead. There is no recovery or treatment program in the world that accepts a dead body.”  

“At the root of it all,” poses Scott, “is how do we define the common good?” Sidewalks, seatbelts, electrical outlet covers: these are all things we agree on, regulate, and require, because human beings knowingly do things that are not good for them. “We already have drug consumption facilities, they’re called bars,” Scott continues. “So why, besides cultural stigma, are we so ill at ease with more safe drug consumption sites, and even dependency itself?”

Adam Phillips and Barbara Taylor write in their book, On Kindness, “The self without sympathetic attachments is either a fiction or a lunatic… dependence is scorned even in intimate relationships, as though dependence were incompatible with self-reliance rather than the only thing that makes it possible.”

It may be true that anything you need makes you weak. But being vulnerable isn’t immoral. If all other therapy operates under the assumption that a patient has agency whatever their mental state may be it may be high time to reassess why we assume people who use drugs are any different.

Kristina Pedersen writes and photographs in Chicago. Her most recent book, What Humble Place As This, documents oil pride in rural Texas. She aspires to play Willy Wonka on Broadway. Follow @kristinapicture on Instagram.

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